accelerated acl rehabilitation 2007
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Accelerated ACL
Rehabilitation
Alex Pinto, MS, ATC
---------------------------------
Hugh West, Jr., MD
K. Donald Shelbourne, MD
Purpose
20 minute overview of one accelerated
ACL rehabilitation technique
Not intended to create a debate over
theories or practices
Due to time constraints
Will challenge current models andpractices
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Objectives
Background on Dr. Shelbourne
Shelboune-based rehabilitation protocol
Rehabilitation considerations
Dr. Shelbourne
Practicing since 1982 with a knee only
focus
Currently limits practice to ACL repair,
simple scopes, and realignments.
Reports a patient profile of >50%
young athletes
Over 80 publications as primary author(knee related)
Holds patent on the cryo-cuff
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Dr. Shelbourne
Claims that most physicians tend to focuson the surgical techniqueStates rehabilitation is an afterthought left to
the physical therapist/athletic trainer to figureout
Demands a long term follow up of patientsEmploys ~4 FTE researchers
Performs all rehabilitation in-houseEmploys 5 PTs and/or ATCs
What Ive Learned About the ACL, KDS, 2003
Shelbournes # of ACL/yr
0
50
100
150
200
250
300
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
2000
2001
2002
2003
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Shelbourne Surgical Technique
Mini-ArthrotomyFor optimal graft placement
Has always used this technique, to maintain
comparability of data
Has allow rehabilitation to be the dependent variable in
outcome
Button fixation
Prevents overtensioning
Allows tight bone-fit
Utilizes a contralateral donor graft, exclusively
Strong graft, allows B2B healing
Claims it allows for early return to sports
What Ive Learned About the ACL, KDS, 2003
Shelbourne KT Values (%)
91
177
2
64
789190909292
88877
26
122115
10
0
20
40
60
80
100
82-86 87-89 90-92 93-95 96-97 98-99 2000-
01
2002-
04
5mm
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Shelbournes Goals of Surgery
Reach symmetry between knees
Range of Motion
Strength
Stability
Overall Function
Would rather have two knees @ 90% of
preop levels than a 100%/70% split of
preop levels
Symmetry
Symmetry is also necessary for all
patients to be able to do normal every day
activities comfortably (stairs, squatting)
Many patients have a stable knee but
never achieve knee symmetry, and yet
they are told they have a good result
All these issues are a problem in some
way, regardless of the graft source
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Emphasize Full
Extension/Hyperextension
70
75
80
85
90
95
100
2 5 7 10 12 15 18
Normal ext/flex Lack ext/normal flex
Normal ext/lack flexion Lack ext/lack flexon
Normal extension is defined by the normal knee preop levels
Aggressive use of extension exercises to return normal extension values
What Ive Learned About the ACL, KDS, 2003
Yrs after surgery
IKDC values
Elite Seat for Extension Block
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Rehabilitation Protocol
Calls into question the notion of graft
strength timelines
Idea that graft is strong/weaker depending on
point in time; related to vascularization
Protocol is built on criteria based
progression rather than time based
progression.
Rehabilitation Protocol
Shelbourne claims it now models manythings he told his patients not to do, theydid anyways, and still got better
Results in 1wk, 2wk, 4wk, 8wk, 12wk, PRNfollow up visits / rehabilitation sessions
Relies on patients to follow guidelines and
perform exercises at homeAllows patients to make decisions
regarding what they can and cannot do;with advisement
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Rehabilitation Cascade of Events
Pre-op rehab: No swelling, full ROM, good leg control
Surgery: Full ROM after graft placement and fixation
Post-op--Full ROM and no swelling
Increase leg strength
Proprioception and agility drills
Sport-specific drills
Competition
Conflicting
goals
What Ive Learned About the ACL, KDS, 2003
Preop/Postop
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Pre-Op
Patient Education
Heel Slides
Towel-Toe Pull/Hyperextension
Quad Sets
Straight Leg Raises
Post-Op
Compression & Cold to prevent hemarthrosis
CPM provides elevation & gently maintains
available ROM
Patients kept for a 23hr stay
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Day After Surgery
Day after surgery
Minimal swelling
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Day after surgery
Normal
Hyperextension
*
Day after surgery
Good terminal
extension, actively
*
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Day after surgery
Flexion measured by
patient using a
yardstick
Excellent self-
assessment tool
Helps when patients
call w/ ?
*
Day after surgery
Good leg control
*
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Day after surgery
Walking for bathroom
privileges
No Nerve Block
*
Discharge day to day 5
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5 days of bed rest1d-5d s/p ALC-r
Bedrest except for bathroom privileges
Heel prop extension exercises 10 min
6x/day
Flexion exercises 6x/day
SLR
Quad Sets
CPM & Cryo/Cuff worn continually exceptduring exercises
First 5 days at home
Knee needs a period of rest, elevation,
and cold/compression to prevent a
hemarthrosis
Without a hemarthrosis
Obtaining full ROM is easier when the knee
does not have an effusion
Knee is less painful
Quad control can be obtained easier
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1st Post-op Visit
1 Week After Surgery
1 week post-op If patient has been
compliant, Minimal
effusion will be present,
ROM will be excellent,
and NM control is
acceptable
Transition Exercises
were possibleHeel slides wall slides
QS/SLR Step
Downs/SAQ
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1 week post-op
Can return to daily activities
Use of cryo/cuff after exercises
Emphasis of a normal gait
Monitor swelling
Adjust activities where needed to prevent
swelling
Return of normal flexion/extension valuesemphasized
2nd Post-op Visit
2 weeks after surgery
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2 weeks Post-Op
Instructions:
Maintain full hyperextension
Increase flexion
Emphasize a normal gait pattern
High repetition exercise for graft-donor site
Use Cryo/Cuff after exercise
Can return to daily activities
Monitor swelling and adjust activities to keepswelling to a minimum
2 weeks Post-op
ROM should exceed125 degreesIf >125, no longer a
primary emphasis
Progress strengthIncrease step height
Long Arc Quads
Bench Hamstrings Increase
proprioceptivechallenges
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3rd Post-op Visit
4th week after surgery
4 weeks post-op
By 4 weeks, ROM
should be normal or
near-normal
Patient must be able to
sit on heels to progress
Sitting on heels will
remain a test prior to
activity
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4 weeks post-op
ADLs should pose no challenge
Patient has prerequisite strength to begin
formal strength training
Patients who advance quickly may be able
to begin basic sport-specific drills
Rules for new activity: No pain during or
after activity, No increase in swelling, Noaltering of gait
Possible Exercises
All high rep, low weight, initially
Commonly include:Leg press
HS Curl
4-Way hip
SL Proprioception (i.e. Stork)
May Include:Slow/Light plyometrics
Basic sports skills (i.e., soccer = dribble, shortkick)
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4 8 weeks after surgery
Patient instructions for next 4 weeksAdditional strengthening with weights single
leg exercises
Begin functional agility program
Sport-specific agility drills
Light controlled sport-specific drills
If an athlete, may utilize ATC at homefacility
If no on-site ATC, support provided viaemail and phone
4th Post-op Visit
~8 weeks after surgery
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8 weeks post-op
If strength is around 70 to 80% (of normal kneepre-op), then begin more intense functional work
Every other day to allow period of rest
Specific functional activity to increase strength
Example controlled jumping drills inbasketball (rebounding, jump shot)
May need to do every other day, depending insoreness in tendon
Continue with weight trainingKeep it specific to the patient!
8 week potential
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8 week potential
8 week potential
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8 week potential
What Ive Learned About the ACL, KDS, 2003
2-4 months after surgery
Continue to progress strength
Continually adapt sport-specific drills tomore closely resemble actual sport
When able to perform drills in a controlledenvironment, reintroduce to actualpractices
When able to practice without difficulty,reintroduce to game situations
Remember, No pain, swelling, or alteredgait
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4 month potential
What Ive Learned About the ACL, KDS, 2003
Important Note
Use Objective
Feedback
Isometric Leg Press w/
tensiometer
1,2,4,8,12
Biodex when capable
4,8,12
3PQ; Leg Press ForcePlace
4,8,12
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Rehabilitation Considerations
If you try to do aggressive strengthening
immediately after ACL reconstruction, the
knee will become swollen, stiff, and painful
So it is best to wait until full ROM has
been obtained before the patient begins
aggressive strengthening
What Ive Learned About the ACL, KDS, 2003
Rehabilitation Considerations
Even then, when doing strengthening
exercises, ROM must be monitored daily
to make sure the knee is not losing motion
Patients highest function will be at the
level of the worst knee/leg
Must obtain symmetry with ROM andstrength for function to be totally normal
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Summary
Regardless of graft source, proper andcomplete pre-op and post-op rehabilitationis necessary
Patient must go through a progression ofsteps to achieve an optimum result
Full symmetrical ROM is required to obtainthe best long-term result
Obtaining full symmetrical ROM, strength,and function is possible
What Ive Learned About the ACL, KDS, 2003
This presentation was created based onoral & written communications with Dr. KDonald Shelborne. It also incorporatemuch information found on a powerpointauthored by Dr. Shelbourne, entitledWhat Ive Learned About the ACL, 2003version.
For more information regarding Dr.
Shelbournes techniques or practice,please visit: www.aclmd.com
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Questions are welcomed at: